Global Doc: Ultrasound Workaround

Author: Dr. Vincent DeGennaro Jr. ’02

The hallway was lined with nearly 200 women. They sat on chairs in the classroom, chairs in the hallway, chairs in the atrium; a few leaned on the railing of the stairs. We had asked them to come in, spending $1,000 on radio ads about free breast cancer screening, unsure what response we’d receive. The response was overwhelming.

This was the first time in the two-year history of the Project Medishare cancer treatment program that we advertised on the radio. It gave us a way to train the Haitian doctors to use ultrasound to screen women for early breast cancer. Even the American radiologist who specializes in women’s cancer hadn’t performed a clinical breast exam since residency; she’d always been referred patients who already identified a lump that required evaluation. Together we performed clinical breast exams on each and every one of 150 women who showed up on day one. Most came in for breast pain, largely a result of wearing bras two sizes too small — a common fashion choice in Haiti. Even with four doctors, it took nearly three hours to determine whether any of the 300 breasts contained suspicious lumps.

Mammograms, the staple of breast-cancer screening in developed countries, aren’t possible in Haiti due to training, equipment and financial barriers. Ultrasound, however, is widely available in Haiti and other developing countries. Once the doctors can use the machine’s sound waves to determine and evaluate the size, shape and consistency of a breast mass, we expect to find tumors at earlier stages. Round, smooth and even consistency likely means benign, while jagged, irregular and heterogeneous consistency tilts toward cancer. The well-trained doctor can even locate small tumors as well as the likelihood that the tumor will be cancerous.

The impact of breast ultrasounds on the effectiveness of the screening program cannot be overstated. Now, low-probability tumors are not biopsied, so the 50-year-old woman who might previously have had a biopsy may go home instead with peace of mind. No incisions, no needle-sticks, no worry while waiting a month for results. The young woman whose tumor might simply have been monitored because of her age may now classify as an intermediate risk that warrants a biopsy. Meanwhile, women with highly suspicious ultrasound results but a negative biopsy were once sent home to monitor growth by themselves. Now they will undergo a repeat biopsy that may well be positive.

When the second American doctor came to continue the training two weeks later, we had the process down. The nurses educated the women en masse in the classroom, using breast models and a short lecture. Those women who still desired an evaluation after learning the facts received a clinical breast exam. Any tumor, suspicious or otherwise, was referred for an ultrasound, many of which were performed by the Haitian doctors.

The results were eye-opening. Of the 500 women who came to the screening over the two weeks of doctor training, 80 received an ultrasound, 22 had a biopsy performed, and five learned that they had breast cancer. Without the advertising, those five women may have come in at a later stage or not come in at all. One of them, 26 years old, has early stage disease. Early diagnosis is critically important, especially in young patients who may have genetically aggressive tumors.

In addition to training the doctors, we also wrote a screening protocol. The existing protocol assumed that mammograms are available and all patients could afford them. The protocol for Haiti accounts for the absence of these factors and attempts to maximize the number of screenings while also limiting costs for the at-large population, most of whom will never develop cancer. The process is complicated and filled with pitfalls, but it is exciting to be on the ground floor of something that will have such widespread impact.

The women also learned how and when to examine their own breasts and were asked to teach the women in their life how to do the same, amplifying the effect. Many learned that a larger bra might reduce their symptoms, albeit reduce the push-up effect they seek.

Two-thirds of these women are under 40 and a third are younger than 30 — not quite the target group for breast cancer, even in Haiti where the median age of diagnosis is 51 years. The good thing is that they are young and the education will, we hope, stick with them for some time to come. On the flip side, nearly 75 percent of them came in complaining of breast pain rather than a mass, skin changes or nipple discharge, the signs of cancer. Again, not our target group.

We know there are thousands of women in Haiti who have early-stage breast cancer and thousands more who have it in the late stages. Where are they? How do we reach them with the education and services? Stay tuned for the awareness and engagement program, which we sincerely believe will change the face of the cancer epidemic — in Haiti and beyond.

Vincent DeGennaro is an internal medicine doctor and a global public health specialist at the University of Florida’s Division of Infectious Diseases and Global Medicine and works half time in Haiti with the nonprofit Project Medishare. See his An American Doctor in Haiti blogs.